M.D. CLAIBORNE & ASSOCIATES, L.L.C.

NEW PATIENT INFORMATION FORM


Section I - Patient Information

First, Middle & Last Name: 
 
Address: 
 City: 
 State:
Zipcode:
    
 Personal Email: 
 Home Number: 
 Cell Phone Number: 
 SSN: 
 Date Of Birth: 
Gender: 
Marital Status: 
Race: 
 
 Employer: 
 Occupation: 
 Work Number: 
 Work Email: 
If referred, by whom: 
 
Primary Language: 

Please note that this office uses English as its primary language. We do not offer any interpreter or translation services. If you require an interpreter, you must provide one for yourself prior to medical treatment.

 

Section II - Minors

Parent/Guardian Name: 
Relationship To Patient:  
Are Addresss & Telephone The Same?: 
 
If address for parent/guardian are not the same, please provide below: 
 
 City: 
 State:
Zipcode:
Home Number: 
 
Please not that children under the age of 18 must be accompanied by a parent or guardian at all visits.

Section III - Insurance


For medical record purposes, please present all current insurance cards to Front Desk for verification and scanning.
 
 Primary Policy Name: 
 Primary Policy Number: 
 Group Number: 
 Are you covered by more than one carrier?

Section IV - Authorizations

 
 Do you give permission for our office to discuss your medical information with family members? (if so please provide info below)
 
 Family Member 1 Name: 
 Family Member 1 Relationship: 
 Family Member 1 Phone: 
 Family Member 2 Name: 
 Family Member 2 Relationship: 
 Family Member 2 Phone: 
 
 Emergency Contact Name: 
 Emergency Contact Relationship: 
 Contact Home Number: 
 Contact Alternate Number: 
 
 May we leave personal medical information on your answering machine or cell phone? 
 How would you like to be addressed from the waiting room?
 How may this office contact you in regards to appointments, treatment, billing? (select all that apply)

Section V - Office Policy

 
 FINANCIAL -  

It is the policy of this office to collect all co payments due at the time of the service. If a balance is due on your account, we will send you a statement for that balance. A total of only 2 statements will be sent. If no payment is received after the second notice, your account will be placed with an outside collection agency for settlement.
 

 APPOINTMENTS - 
 

This office is operated on an appointment only basis. We do not accept walk ins. Your time is just as important as ours. If you are more than 15 minutes late for your scheduled appointment, we ask that you reschedule as a courtesy to others. If you need to cancel an appointment, please call as soon as possible to les us know. Patients who continually do not show for their scheduled appointments without calling to cancel, will be asked to find care with another dermatologist. You will be sent a certified letter informing you of this decision.
 

 HIPAA - 
 We will protect your right to privacy as outlined by the HIPAA laws. Brochures are available throughout this office for your convenience. By signing below, you agree that you understand your rights under this policy.
 
 ASSIGNMENTS - 
 You agree to have all insurance payments sent directly to the doctor performing your service(s). We will file all charges as a courtesy for you to your carrier. There are times when medical information will be requested by your carrier in order to verify and process your charge(s). By signing below, you grant us the right to send this information on your behalf so that your charges may be settled.
 
 HIPAA - ASSIGNMENTS - 
 It is the policy of this office to collect all co payments due at the time of the service. If a balance is due on your account, we will send you a statement for that balance. A total of only 2 statements will be sent. If no payment is received after the second notice, your account will be placed with an outside collection agency for settlement.
 
 TUMOR REGISTRY - 
 This office is mandated by law to record any malignant lesions with the Louisiana Tumor registry. The information is protected under your HIPAA rights and is not forwarded to any other agency. By signing below you agree to allows us to record this information should it apply to you.
 


 
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